Differential diagnosis of Vertigo

and
Meneier’s Disease
Terminologies..
Vertigo: ( latin `verto’: Spinning or whirling movement)
`An illusionary sense that either the environment or one’s own
body is moving’

o Light headeness:
 Blackout
 Fainting attacks
o Instability/imbalance
 Unstadiness with stumbling/falling while walking
o Oscillopsia
o Oscillating vision, objects seem to move back/forth,to jerk
Approach..
 History taking
 Whether balance disorder??
 If yes: central/peripheral
 Etiology

 Thorough clinical neuro otoligical examination

 Investigations
History taking..
o Does the pt have vertigo?
o What happened the first time ?

Association Disease
After head trauma BPPV

Straining Semicicular canal

dehiscence,perilymphatic
fistula,presyncope
Salt load Meniere’s disease

With menstrual periods in women Migraine

Preceding URTI, Vestibular neuritis , labyrinthitis

mumps,herpes zoster oticus
HistoryDuration
taking.. Disease
Seconds BPPV
Vascular compression of VIIIth nerve
 Duration :
Minutes to hours Meniere’s disease
Migraine associated
Acoustic neuroma
Otic syphilis
Cogan’s disease
Days to weeks Vestibular neuritis
Continuous symptoms Migraine
Psychogenic dizziness
Mal de debarquement

Variable duration Inner ear fistula

Labyrinthine concussion
Blast trauma
Barotrauma
Familial vestibulopathy
Superior semicircular canal dehiscence syndrome
 Precipitating factors Disease
Head movement BPPV,vascular loop
Foods-caffeine,cheese,wine Migraine
Stress /lack of sleep
Fluoroscent lights
Loud sound, SSC dehiscence
Pressure Perilymhatic fistula
changes:valsalva,sneezing,coughing Enlarged vestibular aqueduct
Alcohol,exercise Episodic ataxias

Immunosupression (advanced age,stress) Herpes zoster oticus

 Associated ear findings Disease
Hearing loss Ménière's disease; perilymphatic fistula;
acoustic neuroma; cholesteatoma;
otosclerosis; transient ischemic attack or
stroke involving anterior inferior cerebellar
artery,herpes zoster oticus

Tinnitus Meniere’s disease, acute labyrinthitis

Earache Acute middle ear diseases,herpes zoster
oticus
Facial weakness Acoustic neuroma,herpes zoster oticus
Sweating,dyspnea,palpitations Panic attacks
Cardiogenic cause
Aura,Headache Migraine
Neurological signs- Central mass effect,CVA,multiple sclerosis,CP
limbweakness,numbness angle tumour
History taking..
Comorbid illness
 Diabetes mellitus
 Thyroid disease
 Cardiac arrythmias
Medications:
 Aminoglycosides ,cisplatin
 Tranquilisers
 Antiepileptics
 Antihypertensives,diuretics
 Alcohol
 Methotrexate
 Anticoagulants
Clinical examination
Eye movements:
 Spontaneous nystagmus test
 Unilateral vestibular hypofunction
 Jerky nystagmus
 Still head,1 min with eyes closed room darkened and then again
for 1 min with eyes open and looking straight ahead;Frenzel
glasses
 Supressed by visual fixation
 Clinical interpretation:
 Horizontal torsional nystagmus in acute u/l loss of vestibular
function
Positioning testing..
Head movements elicit nystagmus
For posterior semicircular canal BPPV:
 Geotropic torsional nystagmus with the affected ear down
 Delayed onset 2-20secs,transient 45 secs,a/w vertigo,fatigable
Log roll over exercises for lateral semicircular
canal
Positioning testing
 Lateral semicircular canal BPPV: m.c atypical variant (3-9%)
 Pt lying supine with head inclined 30˚forward
 Nystagmus:
 Geotropic
 Stronger with the diseased ear undermost
 Intense vertigo
 Not delayed onset
 Not fatigable
Positional testing..

Benign positional Central positional

nystagmus nystagmus
Latent period 2-10 secs None
Adaptation Within 30 secs Persists
Fatigability Yes None
Vertigo Yes and severe Absent / very mild
Direction Towards undermost ear Variable
Visual fixation Supression None
Other bedside tests..
o Changes in the pressure in the inner ear:
 Valsalva manouvere
 Pneumatic otoscopy
 Tragal compression
o Head Impulse test
o Head shake Nystagmus
o Untenberger test
o Rombergs test
o Cerebellar signs
Vestibulospinal functions :
 CRANIOCORPOROGRAPHY:
 Romberg’s test
 Unterberger /Fukuda stepping test
 Tandem walking/WOFEC
 Romberg’s test:
 Blindfolded,stand erect for 1 minute
 Sway >10cm –abnormal
ukuda stepping test..
Only input –vestibular system
3 parameters:
 Displacement
 Angular deviation
 Angular rotation
50 step /100 step cycle
Eyes closed and hands stretched 90 ˚
Not >45˚ hip flexion
Angle of rotation:
 >30 ˚/>45 ˚ towards the lesioned side
Distance of displacement:
 0.5m/ 1 m
Also positive in asymptomatic pts
ukuda writing test

 Sit erect not touching chair back , elbow and shoulder extended,non used
hand on lap
 Only pen touching the paper
 “A B C… top to bottom”
 Once with eyes open and 3 times blindfolded
 A line drawn from the middle of the 1st letter to the last letter and angle
compared to the original
 6 to 9 ˚- imbalance of vestibular dysfunction
 >9 ˚-diagnosis of vestibular dysfunction
nvestigations
ectronystagmography (ENG)
basic investigation in the management of all patients suffering from
vertigo and equilibrium disorder
allows to calculate various Nystagmus parameters like slow & fast
phase velocity, amplitude, frequency, duration, total number of
beats, latency etc.
Documentary evidence for medico legal purpose, teaching,
publication & patient follow up
It only evaluates function of vestibulo-ocular reflex (VOR)
(vestibulo-spinal & vestibulo-colic reflex -Craniocorpography
& computerized Dynamic posturography )
 Principle

 Cornea-retinal potential difference.

 Voltage differences can be recorded for eye movements.
 Electro-occulography to objectively measure eye movements.
sentially ENG consists of 3 parts:
Visual-oculomotor evaluation:
 Three eye movements assessed as part of the ENG are
saccades, smooth pursuit, and optokinetic nystagmus.
Positioning/positional testing,
 Gaze stability, ocular flutter, spontaneous nystagmus, and
latent nystagmus.
Vestibulo-oculomotor function.
 The bithermal caloric test.
 Advantages of Electronystagmograpy

The results of the test are quantified, and there are well-defined
normal limits;
Because ENG provides accurate documentation of results, it can be
used to follow up the patient with known vestibular disease;
Standardized documentation is helpful in medical-legal and
workers’ compensation cases;
It is the only test that assesses each ear separately and can give side
of lesion localizing information
 mitations
ENG tests only the lateral semicircular canal and provides little
information about the status of the posterior or superior
semicircular canals, utricle, or saccule.
Relatively insensitive to torsional nystagmus. However, this
limitation is easily overcome using VNG.

ideo-Oculography

Magnetic Search Coil Technique

technique determines eye position by locating the pupil and tracking its center; the internal
uter program plots, measures, and analyzes the eye movement similar to traditional ENG.
ially important in evaluating patients with benign paroxysmal positional vertigo (BPPV).
nystamographic Advantage
tracings are clean with no drift
technique is easier and quicker than using electrodes
only one calibration is necessary
eliminating the cost of accessories
Torsional nystagmus
nystamographic Disadvantage
More expensive, some patients with significant claustrophobia may not tolerate the
sensation of confinement
Patients with ptosis, pupil-obscuring eyelashes, or other eye abnormalities may be difficult
Patient in a cage controlling a magnetic field
The patient wears a soft contact lens in which a wire coil is embedded
Eye movement effects a change in the magnetic field, which is recorded
Advantage
 Very high-resolution data for all types of eye movements, including torsional nystagmus.
Disadvantages
 Slight discomfort to the patient (owing to the lens)
 Very high cost of the equipment

This procedure has yet to gain widespread acceptance and is rarely used
he rotational tests..
Test of vestibulo-ocular reflex
Carried out by BARANY
Passive and active
Rotary chair tests
Vestibular autorotational
testing(VAT)
omputerized dynamic posturography
Developed by Nashner and Black
Potential mechanism for all sensory system evaluation
Planning and monitoring course of vestibular rehabilitation
Suspected malingering,conversion disorder
VEMP test
Testing the vestibulo-collic reflex
Pure tone sounds of 500 Hz at 95-105dB
3-5 stimuli/second
SCM-tonically contracted
Absent VEMP
 Failure of activation of SCM
 Saccular disorder
 Menier’s disease
Lower threshold in VEMP with CHL-SSC dehiscence
Meniere’s disease
Prosper Meniere -1861 first described the symptom cpmplex
Before 1938, it was used as a generic term for peripheral
vertigo
Whites
M:F-1:1
4th -5th decade
B/L-50% within 5 yrs-if second ear involved rapidly-AIED*
Familial occurrence-10%-20% cases-a/w migraine
Autosomal dominant
a/w specific MHC’s- HLA B8/DR3 Cw7—autoimmune
etiology
athogenesis..
Hallmark :endolymphatic hydrops
Overaccumulation of endolymph at the expense of perilymphatic
space

Inadequate absorption of endolymph by endolymhatic sac-present

theory

HPE : perisaccular fibrosis and decreased duct size

Imaging:shorter endolymphatic drainage systems-distance
between the posterior SSC and posterior fossa
thophysiology..
Rupture of membranous labyrinth
Leakage of K+ rich endolymph in perilymph
High concentration of extracellular K+

Depolarizes nerve cells

Inactivation

rease in auditory and vestibular neuronal outflow-s/s

ling of the membranes-restoration of chemical mileu-resolution of s/s

eated exposure – chronic detoriation in inner ear function

tiology..
ultifactorial,
common endpoint of variety of injuries/anatomic variables

Unknown cause: Meniere’s disease

Secondary endolymphatic hydrops
 Viral infection-mumps,measles-delayed endolymphatic hydrops
 Ischemia of the endolyphatic sac/inner ear
 Autoimmune-association with HlA-Ab to HSP70
 a/w development of hydrops-acute otitis media,labyrinthitis,congenital inner
ear
linical presentation..
Typical triad
 Recurring attacks of vertigo(96.2%)
 Tinnitus (91.1%)
 I/L hearing loss(87.7%)

Cochlear Meniere’s disease

Vestibular Meniere’s disease
Recurrent vestibulopathy and atypical Meniere’s disease
Clinical course-highly variable
Cluster of attacks separated by long remissions
Vertigo Ceases spontaneously in 57%-2 yrs,71%-8.3yrs
Tumarkin crisis / drop attacks: “feeling of being pushed”/ “world is moving”
 Sudden unexplained falls without LOC/associated vertigo
 Acute utriculosaccular dysfunction
 2-6%
 Clusters and then remits
Lermoyez:
 Tinnitus and hearing loss precede and worsen with the onset of
vertigo
nvestigations..
ENG
 Reduction in caloric response-48%-73.5%
 Complete absence-6-11%

Head thrusting test

 Asymmetry is subtle-29%pts

Electrocochleography
 SP/AP ratio increases
 62% pts have elevated ratios
Dehydrating agents
 Urea,glycerol,furosemide
 10dB or more improvement in at least 2 frequencies
 12% improvement in speech discrimination scores

VEMP
 Elevated VEMp threshold with flattened tuning
lectrocochleography
Recording of 3 parameters:
 Cochlear microphonics
 Summating potential-complex
 Action potential– auditory nerve
In meniere’s relative increase of SP attributed to the basilar membrane
Differential diagnosis of episodic vertigo

Disease History and examination Investigations

1 Auto Immune B/L rapidly progressive CBC,DLC,ESR,RF,ANA,

Inner Ear disease SNHL,(monthly intervals), Anti dsDNA,APLA
AIED Recurrent vertigo , Ab,C3,C4,Western Blot
Ocular inflammation, Assay for anti HSP-70,
Depigmentation (VKH), RESPONSIVENESS TO
URTI,LRTI(WG), CORTICOSTEROIDS
Recurrent
thrombosis,spontaneous
abortions(APLA)

2.Perilymphatic Dysequilibrium with nose Intra-op--- Fluid,

fistula blowing/lifting heavy wt, B2 transferrin,
Atecedent H/o trauma,ear HRCT
surgery,
HENNBERT’S SIGN
TULLIO’S PHENOMENON
Disease History and clinical features Investigations
3.Migraine Recurrent characteristic
headache-
throbbing,pulsatile,unilateral,
nausea,vomiting,photophobia,pho
nophobia,aura,parasthesias

4.Otosyphilis Late otosyphilis- VDRL,FTA-AB,MHA-TP

HUTCHINSON’s TRIAD-
EXCLUSIVE FEATURE,
Hennbert’s and tullio’s
phenomenon

5.Labyrinthine H/O trauma PTA-NIHL with 4 KHZ loss

concussion Vegetative symptoms- MR=imaging
nausea,vomiting
Vertigo-subsides over days to
weeks

6.EVAS Hearing loss since childhood, CT->1.5mm at midpoint

Progresses with minor head
trauma,
Vertigo-late onset-adulthood
Treatment options..
Aim
 Stop vertigo, abolish tinnitus and reverse hearing loss
 Spontaneous improvement in 60%-80%cases
 Placebo effect

3 broad options
o Dietary
o Medications
o Surgery
Dietary modifications..
o Salt restriction
o Diuretics
 Neither has its efficacy confirmed by double-blind placebo
controlled studies*
o Carbonic anhydrase inhibitors-Acetazolamide
 Not more effective than diuretics

*
Medications ..
o Vasodilators : strial ischemia
 Betahistine
o Symptomatic treatment:
 Antihistaminics
 Anti-emetics
 Sedatives
 Anti-depressants
 Psychiatric treatment
 Local overpressure therapy
Rationale use
Energy of the pressure pulses displaces the perilymphatic fluid
stimulates the flow of endolymphatic fluid --- results in a reduction of
endolymphatic fluid

o Meniett device: FDA approval since 2000

 Complex pulses 20 cm water over 5 min period
 3 times daily
 Ventilation tube placed thru tympanic membrane
Significant decrease in vertigo for the first 3 mths,later similar to placebo
Intratympanic Injection
o Gentamicin
 Through tympanostomy tube/through tympanic membrane
 Vestibulotoxicity high relative to cochleotoxicity
 90% complete control of vertigo,3% SNHL*
 Current regime:
Low-dose (16 mg/mL) gentamicin buffered with HCO3 --
injected intratympanically by a 22-gauge fine needle--
through posteroinferior quadrant of tympanic membrane—
total amount 1ml
Lie in supine position with the effected ear up for 30 minutes
Ecouraged not to swallow
Intratympanic injection..
o Dexamethasone :
 Addresses the autoimmune component
 Intractable vertigo
 Functional hearing left
 Concentrations ranging from 2-24 mg/ml
 Repeat every 3 mths
 Complete resolution in 82% v/s 57%receiving saline*

*.
Surgical treatment..
Indications
 “Intractable vertigo in whom medical therapy has failed”

o Cocleosacculotomy
o Endolymphatic sac surgery
o Ablative surgery
Cochleosacculotomy

 Create a permanent
communication to
equilibriate endolymphatic
and perilymphatic pressures
 Alternative to
labyrinthectomy in elderly
patients with preexisting
hearing loss
Endolymphatic sac surgery
Ablative vestibular surgery
Labyrinthectomy
Recurrent/persisting vertigo with severe to profound SNHL
1. Transcanal
2. Transmastoid –gold standard
Vestibular nerve section:
Selective vestibular nerve section
Take home message

o Identify vertigo!!!
o History taking
o Clinical neurootological examination
o Diagnostic investigations-last resort
Thank
you…………..